| Condition | Major Pathogens | First Choice Therapy | Alternative Therapy | Comments |
|---|---|---|---|---|
|
Herpes simplex encephalitis or other disseminated disease regardless of immune status, including suspected HSV encephalitis pending diagnostic evaluation See guidance on HSV disease in neonates and young infants < 3 months old |
Herpes simplex virus |
Age 3 months to < 12 years: Acyclovir >=12 years: Acyclovir |
ID consult recommended Duration: 21 days Some experts may recommend suppressive oral acyclovir following acute treatment of HSV encephalitis in infants 3-12 months of age. Consult ID and refer to neonatal guidelines for suppressive dosing if recommended |
|
| Herpes simplex, orolabial disease (non-neonatal) in immuno-competent hosts | Herpes simplex virus |
Acyclovir OR Valacyclovir |
For patients unable to tolerate enteral therapy: Acyclovir Enteral therapy is preferred if possible. IV therapy increases risk for nephrotoxicity due to crystal nephropathy with greater risk associated with dehydration, higher dose and faster rate of infusion. If IV therapy is given, ensure good hydration status Transition to enteral therapy as soon as possible |
Episodic treatment most likely to be beneficial if initiated within 72 hours of onset Duration: Usually 5-7 days, dependent on clinical resolution; though may treat with single day (2 dose) duration with valacyclovir in adolescents Chronic suppressive therapy may be considered for patients experiencing 6+ outbreaks/year |
| Herpes simplex, orolabial disease (non-neonatal) in immuno-compromised hosts | Herpes simplex virus |
Initial IV therapy for patients at high risk for progression or with severe symptoms or impaired enteral intake: Acyclovir Transition to enteral therapy when patient shows clinical improvement and is able tolerate enteral treatment |
Enteral therapy for patients with mild-moderate symptoms, low risk for progression: Acyclovir OR Valacyclovir |
Consider ID consult In immuno-compromised host, start treatment as soon as possible (based on clinical suspicion) and regardless of days elapsed since onset Duration: Until complete healing of the lesions, generally 7-14 days |
|
Herpes simplex genital infection in adolescents, first episode |
Herpes simplex virus |
Valacyclovir OR Acyclovir |
For non-adolescent age patients, consult ID/ASP for recommendations |
First reported episode of genital lesions is suggestive of primary infection, treatment is generally indicated and should be started as soon as possible and regardless of days elapsed since onset Duration: 7-10 days. Treatment can be extended until complete healing of lesions. Starting suppressive therapy may be considered after first episode, and is indicated starting at 36 weeks gestation in pregnant patients (see below) For patients who are pregnant and near delivery, further distinction of primary vs non primary infection should be made via lab testing to guide management of neonate, refer to published guidelines |
|
Herpes simplex genital infection in adolescents, prevention or treatment of recurrent episodes |
Suppressive therapy, non-pregnant patient: Acyclovir OR Valacyclovir Suppressive therapy, pregnant patient: Acyclovir OR Valacyclovir |
Episodic therapy for non-primary infection: Acyclovir OR Valacyclovir
|
Duration: Suppressive therapy for 6-12 months following first episode may prevent recurrence and improve quality of life, and decrease risk of transmission to sexual partners. Suppressive therapy is also indicated for pregnant patients with history of genital HSV beginning at 36 weeks gestation. Alternatively, episodic treatment of recurrent episodes may be used. Initiate therapy within 1 day of lesion onset or during prodrome for 5 days |
References:
American Academy of Pediatrics. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021.
Lee DH, Zuckerman RA, AST Infectious Diseases Community of Practice. Herpes simplex virus infections in solid organ transplantation: Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice. Clin Transplant 2019; 33:e13526.
Kimberlin DW, Baley J, Committee on Infectious Diseases, et al. Guidance on management of asymptomatic neonates born to women with active genital herpes lesions. Pediatrics 2013;131:383–6.
Workowski KA, et al. Centers for Disease Control and Prevention. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep 2021;70:1-187.
American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. Management of genital herpes in pregnancy: ACOG Practice Bulletin, Number 220. Obstet Gynecol 2020; 135:e193.
Pediatric Empiric Antimicrobial Therapy Guidelines
This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites.
These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.
For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK.
The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.